HomeMy WebLinkAbout105 Marratooka LnHIGHWAY DEPARTMENT
Pe~onic Lane
Peconic: New York 11958:
(631} 765- 31~10
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town
of Southold for the issuance of an Excavation Permit pursuant to Chapter 83 of the
Code of the Town of Southold, Suffolk County, New York, and other appliCable laws,
ordin&nces or regulations for the eXcavation herein described. The applicant agrees
to comply with all applicable laws, ordinances, codes and regulations, and to permit
authorized inspectors to mlake~ necessary inspections of the job site.
Pr,nttr_T. yPL. ,. . , t-
2I. .~'~ ,~_Name~f~Owner o~r~f pir~emises ,, ~ ~,,~ ,~'-[ /~r~~, ,L//! ~Z~ c.__ ~-~'~ --
(a) Is construcUon I,ted within 75 fee~t ~t d~al ?&a:ds///? *~Ves~o--- r"~f'F~'f~'t'/'.~
*If yes, other Town permits may be required.
~) Builder's License Ho. Pluraber~s License No.
Electricia,'s License Ho. ~ a S~) Oth~rrade,t uc~,e No; / /~
Signatu~ of App,U~cant
~) a} Attach plot plsn showing location of Prol~*ed ~x~cavat on and ro atlonahIp to
adlolning pr~nl~es or public streets or stoas, and giving · detallod descrip-
tion of I~out of
b) ~t~ch ~ll otber n~c~*~ry p*mlt~ ~nd Iic~n*ss for thi~ prol~t.
c} ~or~ ~v~r~ by thl* ~pplimtion m~y not commonc~ ~for* i~ua~ of ~
Highway Excavation Permit by the Town Clerk.
~) Tax Map: Sect,o. i / ~/ . B,eck~/~ . 'ot
7) Starting Date: Completion Date
8) Work Schedule:
Phase
Excavation .........................................
Facility Installation .................................
Backfill ~ Compaction ..............................
Pavement Replacement ..............................
9) Under which authority is the application made:
10, Estimated Cost of Proposed Work: ,
11) Remarks:
Completion Date
D-39 Page 1 of 3
12)
13)
Insurance Covetable: [Attach copy)
a) Insurance
b) Policy # '~'"'"~,~ ~ ~"~
c) State whether policy of certification on file with the Highway Depart-
ment:
A2.
B.
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury,
and $50,000 property damage·
Security;
a) Surety Bond or Certified Check provided in the
total amount of $
b} Maintenance Bond provided: 2 years or 3 years
Fees for applications and permits: Basic Application _ee ........ . .....
Al. Z /Service Connections excavations ~ $20.00 = $ ~ /
/Additional Excavations same service ~1 $10.00 = ~.
N~.
Excavations 18" In depth or less:
0-100 I.f. = $10.00
I.f. ~ $0.10- $
Add ittonal
Excavations 18" In depth to 5~ in depth:
0-100 I.f. = $30.00
I.f. J $0.30 = $
Additional
Excavations 5' in depth and over:
0-100 I.f. = $50.00
I.f. ~ SO.SO = $
Additional
NO,
Additional
Utility Repair Excavations e$~10.00
Repairs same service ~ $5.00
F. Notice to public*utilities proof must be provided and attached to
this appliCation prior to issuance of Permit,
Received by the Town Clerk
Hote:
D-39
Authorization Is hereby granted to the Town Clerk of the Town of Southold to
issue a Highway Excavation Permit to:
in'accordance with this application.
SUPERINTENDENT OF HIGHWAYS
TOW. OUT.OLD;
I~eter I~. Harris
/ Date
~ Date
Permit No. ~JC~J
Permit expires one (1) year from Date of Issuance.
No work to start without ~18 hour notice to the Superintendent of Highways.
Permit must be available for inspection.
Page 2 of 3
LONG ! SLf~ND, I NC
FAX NO. :727 786 2861
~6 20~ 08:3~q1'1 P~
J & M Long, Island, lnc
facsimile transmittal
Re:
ATT;
':"
LONG I BL.AND~ 114C FAX HO. : 72 ? 7S6 2861
~RD' CERTIFICATE OF L~BILITY
............
PO eOX ~7 ~
'tOWN OF
ROAD
~O~THOLD, N~N YORK t 19~
~OT~L